Transforming the VA will be daunting task

Jul. 7, 2014 - 06:00AM
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President Barack Obama is flanked by Vice President Joe Biden and former Procter & Gamble exec Robert McDonald (right), Obama's nominee to get the scandal-plagued VA back on track. (Dennis Brack/Getty Images)

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It seems nearly every day there's more bad news about the U.S. Department of Veterans Affairs and how it has treated those who served in the military.

Whether it's confirmation that veterans died while awaiting care, patient wait-time records being manipulated to trigger staff bonuses, or the VA consistently ignoring whistle-blower warnings about dangerous practices, it's been a particularly embarrassing time for the VA.

In Congress, a bipartisan House and Senate committee met for the first time June 24 to craft legislation to change the way the nation's largest integrated health-care system does business. The goal is to get a bill to President Barack Obama this month, but it has been delayed because of the bill's potential cost.

Obama last week set the stage for internal change at the VA, nominating West Point graduate Robert McDonald, most recently CEO and chairman of Procter & Gamble, as the new VA secretary. His nomination is subject to confirmation of the U.S. Senate.

Obama also discussed his outlook for administrative revisions that, while not remaking the agency, could change every veterans' health-care experience at the VA. Among them: hiring more medical professionals, paying closer attention to whistle-blower complaints, and seeking authority for the VA secretary to fire senior leaders who are now protected by statute.

The climate in Congress makes at least some change at the VA likely, though a complete overhaul of the troubled agency is doubtful. The VA health-care system is just too big, and its customers — veterans — are loyal despite the problems that ignited the scandal.

Congress also has limited time and political will for major reform, given the approaching elections.

Lawmakers are considering a VA package that some congressional analysts say will cost more than $35 billion. Even if lawmakers pay for more doctors, specialists and nurses and implement changes making it easier to fire hospital administrators and managers, will it be enough?

McCain, R-Ariz., a member of the House and Senate Veterans' Affairs Conference Committee, isn't sure money alone will fix the problems. And he's not alone in his skepticism. Veterans groups and those who monitor health care say the VA has a herculean task.

"Unless we change the way the VA does business, we will not change anything," McCain said in an interview with The Arizona Republic.

But cost has already become an issue. McCain says the Congressional Budget Office's estimate of the Senate VA reform bill cost is too high. The competing House VA bill's cost is projected at $44 billion.

"We just think that it's way, way out of line, and ... that has been a problem because a lot of our deficit hawks are­ saying, 'Gee, $35 billion?' " McCain said.

McCain said he was confident a compromise would allow VA legislation to pass this month at a cost lower than CBO's $35 billion estimate.

"It has to," he said. "The American people will demand it."

He called fixing the VA "the definition of an emergency." But even if Congress allows veterans to get expedient care, he said the agency won't truly become healthy unless there is a complete change in leadership.

Two veterans groups agreed with McCain that the VA won't solve its problems without new leadership.

"Right now is the best time to reform the VA," said Ralph Bozella, chairman of the American Legion's National Veteran Affairs and Rehabilitation Commission. "What they need is a cultural change in the organization."

The VA could, at a minimum, implement simple changes like having hospital staff greet veterans with a smile and extend some common courtesy, Bozella said. The VA also needs to do a better job of partnering with veterans groups, which would rally around a reformed agency, he said.

The Legion, with 2.4 million members and nearly 14,000 posts across the country, was one of the first groups to call for the resignation of VA Secretary Eric Shinseki. The organization's bylaws keep it from endorsing or opposing a political nominee.

"However, we do look forward to monitoring the confirmation hearings and listening to Robert McDonald's plan to correct the policies that have led to the systemic scandals," National Commander Daniel M. Dellinger said. "He will need to have complete hiring and firing authority, along with a willingness to see that those who committed illegal acts are prosecuted."

Dan Caldwell, an executive with Concerned Veterans for America, said the VA culture will change only if there are numerous personnel changes at the VA central office in Washington, D.C., and if dozens of hospital administrators are removed.

"There is no accountability. There is a belief in the VA that they are doing fine, and it doesn't matter," said Caldwell, who noted it can take months to terminate a federal employee.

Rep. Ann Kirkpatrick, D-Ariz., is among numerous members of Congress who have called for more accountability within the VA.

Kirkpatrick, a member of the House and Senate Veterans' Affairs Conference Committee, said the VA needs funding to upgrade computer software to improve patient scheduling. She also said the VA should hire an outside scheduling expert.

Heather Ross, a clinical instructor at Arizona State University who studies complex health-care systems, said the scheduling system at the VA is "fundamentally broken." Until it is repaired, she said, it will remain difficult to accurately schedule patients because of outdated technology to track veterans.

"The record system needs to be fixed. At the end of the day, it's a software issue," said Ross, also a nurse practitioner.

Ross said there should be consequences for staff who manipulated patient wait-time records, but "firing people will not fix the problem."

Karen Watts, a Silicon Valley entrepreneur and former Mesa resident, has firsthand experience with the VA's scheduling problems.

Watts, whose process-software company Apparancy has developed an online program to help veterans fill out benefits applications, said her stepfather was approved last year for back surgery at the Palo Alto, Calif., VA facility.

She said the scheduling system was so bad that the hospital couldn't give her stepfather a firm date on when he would have the surgery. The World War II veteran waited roughly six months after being told he was approved for surgery to get a date.

"This is a joke, but it's really not a joke because people are dying," Watts said. "There are plenty of tools out there to solve these problems."

Watts, who graduated from Mesa High School in 1989, said the VA's scheduling system is akin to the video game Pong, released in 1972.

"That's the same technology they are using at the VA," Watts said. "It's not super easy to fix these problems, but there is no excuse that they are stuck in this level of technology."

Besides improving its technology, the VA needs better data on patient demand to allocate resources better, said Phillip Carter, senior fellow and director of veterans research at the Center for a New American Security.

Carter added that the VA should further leverage the private sector for non-service-related care and use provisions under the Affordable Care Act as an option for veterans' health care.

Robert Book, senior research director at the Health Systems Innovation Network, a health-policy consulting firm, said one alternative to direct health care from the VA is for the agency to subsidize veterans' private health insurance, using a sliding scale based on the current priority criteria for veteran-care eligibility.

"With a very few exceptions, most of the health-care needs could be met by paying civilian doctors and civilian hospitals," Book said.

Marc Landy, a Boston College political-science professor whose research focuses on the presidency and the executive branch, said the organizational structure of a large, federal agency like the VA is not set up to efficiently provide health care.

"It is always surprising how much trouble these big federal departments have in creating sensible command structures. This is, horribly, not unique to the VA," Landy said.

He said the political ramifications of decentralizing and outsourcing VA care in the long run would likely result in job cuts and a decreased role for the VA health-care system. Congress will not want to permanently relinquish control over the VA, he said.

"That's why it's very important to do this now. It seems to me, with congressional elections coming up, there's advantage to improving the VA. It's not a partisan matter. Both parties love the veterans," Landy said.